Use of multiple rods and proximal junctional kyphosis in adult spinal deformity surgery.

OBJECTIVE: Multiple rods are utilized in adult spinal deformity (ASD) surgery to increase construct stiffness. However, the impact of multiple rods on proximal junctional kyphosis (PJK) is not well established. This study aimed to investigate the impact of multiple rods on PJK incidence in ASD patients. METHODS: ASD patients from a prospective multicenter database with a minimum follow-up of 1 year were retrospectively reviewed. Clinical and radiographic data were collected preoperatively, at 6 weeks postoperatively, at 6 months postoperatively, at 1 year postoperatively, and at every subsequent year postoperatively. PJK was defined as a kyphotic increase of > 10° in the Cobb angle from the upper instrumented vertebra (UIV) to UIV+2 as compared with preoperative values. Demographic data, radiographic parameters, and PJK incidence were compared between the multirod and dual-rod patient cohorts. PJK-free survival analysis was performed using Cox regression to control for demographic characteristics, comorbidities, level of fusion, and radiographic parameters. RESULTS: Overall, 307/1300 (23.62%) cases utilized multiple rods. Cases with multiple rods were more likely to be revisions (68.4% vs 46.5%, p < 0.001), to be posterior only (80.7% vs 61.5%, p < 0.001), involve more levels of fusion (mean 11.73 vs 10.60, p < 0.001), and include 3-column osteotomy (42.9% vs 17.1%, p < 0.001). Patients with multiple rods also had greater preoperative pelvic retroversion (mean pelvic tilt 27.95° vs 23.58°, p < 0.001), greater thoracolumbar junction kyphosis (-15.9° vs -11.9°, p = 0.001), and more severe sagittal malalignment (C7-S1 sagittal vertical axis 99.76 mm vs 62.23 mm, p < 0.001), all of which corrected postoperatively. Patients with multiple rods had similar incidence rates of PJK (58.6% vs 58.1%) and revision surgery (13.0% vs 17.7%). The PJK-free survival analysis demonstrated equivalent PJK-free survival durations among the patients with multiple rods (HR 0.889, 95% CI 0.745-1.062, p = 0.195) after controlling for demographic and radiographic parameters. Further stratification based on implant metal type demonstrated noninferior PJK incidence rates with multiple rods in the titanium (57.1% vs 54.6%, p = 0.858), cobalt chrome (60.5% vs 58.7%, p = 0.646), and stainless steel (20% vs 63.7%, p = 0.008) cohorts. CONCLUSIONS: Multirod constructs for ASD are most frequently utilized in revision, long-level reconstructions with 3-column osteotomy. The use of multiple rods in ASD surgery does not result in an increased incidence of PJK and is not affected by rod metal type.

Perioperative Complications and Health-related Quality of Life Outcomes in Severe Pediatric Spinal Deformity.

STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To evaluate perioperative complications and mid-term outcomes for severe pediatric spinal deformity. SUMMARY OF BACKGROUND DATA: Few studies have evaluated the impact of complications on health-related quality of life (HRQoL) outcomes in severe pediatric spinal deformity. METHODS: Patients from a prospective, multicenter database with severe pediatric spinal deformity (minimum of 100 degree curve in any plane or planned vertebral column resection (VCR)) with a minimum of 2-years follow-up were evaluated (n=231). SRS-22r scores were collected preoperatively and at 2-years postoperatively. Complications were categorized as intraoperative, early postoperative (within 90-days of surgery), major, or minor. Perioperative complication rate was evaluated between patients with and without VCR. Additionally, SRS-22r scores were compared between patients with and without complications. RESULTS: Perioperative complications occurred in 135 (58%) patients, and major complications occurred in 53 (23%) patients. Patients that underwent VCR had a higher incidence of early postoperative complications than patients without VCR (28.9% vs. 16.2%, P =0.02). Complications resolved in 126/135 (93.3%) patients with a mean time to resolution of 91.63 days. Unresolved major complications included motor deficit (n=4), spinal cord deficit (n=1), nerve root deficit (n=1), compartment syndrome (n=1), and motor weakness due to recurrent intradural tumor (n=1). Patients with complications, major complications, or multiple complications had equivalent postoperative SRS-22r scores. Patients with motor deficits had lower postoperative satisfaction subscore (4.32 vs. 4.51, P =0.03), but patients with resolved motor deficits had equivalent postoperative scores in all domains. Patients with unresolved complications had lower postoperative satisfaction subscore (3.94 vs. 4.47, P =0.03) and less postoperative improvement in self-image subscore (0.64 vs. 1.42, P =0.03) as compared to patients with resolved complications. CONCLUSION: Most perioperative complications for severe pediatric spinal deformity resolve within 2-years postoperatively and do not result in adverse HRQoL outcomes. However, patients with unresolved complications have decreased HRQoL outcomes.

Distal junctional kyphosis in adult cervical deformity patients: where does it occur?

PURPOSE: To evaluate the impact of the lowest instrumented vertebra (LIV) on Distal Junctional kyphosis (DJK) incidence in adult cervical deformity (ACD) surgery. METHODS: Prospectively collected data from ACD patients undergoing posterior or anterior-posterior reconstruction at 13 US sites was reviewed up to 2-years postoperatively (n = 140). Data was stratified into five groups by level of LIV: C6-C7, T1-T2, T3-Apex, Apex-T10, and T11-L2. DJK was defined as a kyphotic increase > 10° in Cobb angle from LIV to LIV-1. Analysis included DJK-free survival, covariate-controlled cox regression, and DJK incidence at 1-year follow-up. RESULTS: 25/27 cases of DJK developed within 1-year post-op. In patients with a minimum follow-up of 1-year (n = 102), the incidence of DJK by level of LIV was: C6-7 (3/12, 25.00%), T1-T2 (3/29, 10.34%), T3-Apex (7/41, 17.07%), Apex-T10 (8/11, 72.73%), and T11-L2 (4/8, 50.00%) (p < 0.001). DJK incidence was significantly lower in the T1-T2 LIV group (adjusted residual = -2.13), and significantly higher in the Apex-T10 LIV group (adjusted residual = 3.91). In covariate-controlled regression using the T11-L2 LIV group as reference, LIV selected at the T1-T2 level (HR = 0.054, p = 0.008) or T3-Apex level (HR = 0.081, p = 0.010) was associated with significantly lower risk of DJK. However, there was no difference in DJK risk when LIV was selected at the C6-C7 level (HR = 0.239, p = 0.214). CONCLUSION: DJK risk is lower when the LIV is at the upper thoracic segment than the lower cervical segment. DJK incidence is highest with LIV level in the lower thoracic or thoracolumbar junction.

Use of the Global Alignment and Proportion score to predict postoperative health-related quality of life in adult spinal deformity surgery.

OBJECTIVE: The purpose of this study was to validate the Global Alignment and Proportion (GAP) score as a predictor of health-related quality of life (HRQOL) outcomes for patients undergoing adult spinal deformity (ASD) surgery. METHODS: This was a retrospective cohort study of patients with ASD undergoing long-segment spine fusions (≥ 5 vertebrae fused) at a single institution over a 2-year period (n = 85). Radiographic parameters were measured at preoperative, 6-week postoperative, 1-year postoperative, and 2-year postoperative visits. GAP scores were calculated using 4 sagittal parameters: relative pelvic version, relative lumbar lordosis, lordosis distribution index, and relative spinopelvic alignment. Patients were stratified into 3 GAP categories at each time point: proportioned (score 0-2), moderately disproportioned (score 3-6), and severely disproportioned (score ≥ 7). HRQOL outcomes were collected at preoperative, 1-year postoperative, and 2-year postoperative visits; these measures included patient self-reported outcome measures (i.e., PROMIS), Scoliosis Research Society-22 spinal deformity questionnaire (SRS-22), and Oswestry Disability Index (ODI) scores. RESULTS: Overall, 42% of cases were revision surgeries and 96.5% of patients underwent fusion to the sacrum. The mean preoperative GAP score significantly improved from preoperative (7.84) to immediate postoperative (3.31) assessment (p < 0.001). Similarly, the percentage of patients categorized as proportioned improved from 9.4% at preoperative to 45.9% at immediate postoperative evaluation. The preoperative GAP score or category was not significantly associated with any preoperative HRQOL outcome metrics. The immediate postoperative GAP score was not correlated with any 1-year HRQOL outcomes. However, the immediate postoperative GAP score was significantly associated with 2-year SRS-22 outcomes, including SRS-22 function (r = -0.35, p < 0.01), self-image (r = -0.27, p = 0.044), and subtotal (r = -0.35, p < 0.01) scores. As compared to severely disproportioned patients, proportioned patients had better SRS-22 pain (4.08 vs 3.17, p = 0.04), satisfaction (4.40 vs 3.50, p = 0.02), and subtotal (4.01 vs 3.27, p = 0.036) scores. The immediate postoperative GAP score was also significantly associated with 2-year PROMIS outcomes, including PROMIS pain (r = 0.31, p = 0.023) and physical function (r = -0.35, p < 0.01) scores. As compared to severely disproportioned patients, proportioned patients had better PROMIS pain (53.18 vs 63.60, p = 0.025) and physical function (41.66 vs 34.18, p = 0.017) scores. Postoperative GAP score or category did not predict any ODI outcomes. CONCLUSIONS: The postoperative GAP score is a predictor of long-term HRQOL outcomes following ASD surgery, and proportioned patients are more likely to have less pain and be satisfied with their surgery. However, the postoperative GAP score does not predict outcomes as measured by ODI.

Value of Evoked Potential Changes Associated with Neck Extension Prior to Cervical Spine Surgery.

Background: Multimodal intraoperative monitoring (MIOM) is a useful tool to warn surgeons to intervene for intraoperative spinal cord injury in cervical spine surgery. However, the value of MIOM remains controversial before cervical spine surgery. Objective: To explore the value of MIOM in early detecting spinal cord injury associated with neck extension before cervical spine surgery. Methods and Materials: Data of 191 patients receiving cervical spine surgery with the MIOM were enrolled from June 2014 to June 2020. The subjects were divided into a group of evoked potentials (EP) changes and a group of no EP changes for analysis according to the monitoring alerts or not. Results: Five (2.62%) patients showed EP changes associated with neck extension during intubation or positioning. After early different interventions, such as repositioning and timely surgical decompression, none or transient postoperative neurological deficits were observed in four cases, and only one case was with permanent neurological deficits. The average preoperative Japanese Orthopaedic Association (JOA) scores of the group with EP changes were lower than those of the group with no EP changes (P = 0.037 < 0.05). There was no statistical significance in gender, average age, mean Pavlov ratio, and the minimum Palov ratio between the two groups (P > 0.05). Conclusions: The MIOM could identify spinal cord injury associated with neck extension before cervical spine surgery. Active and effective interventions could prevent or reduce permanent postoperative neurological deficits. Severe spinal cord compression might be a risk factor for EP changes.

Da Vinci robot-assisted laparoscopic retroperitoneal debridement for lumbar septic spondylodiscitis: A two-case report.

The anterior approach is one of the widely used surgical treatments for lumbar spondylodiscitis, but it has the disadvantages of large trauma and a high incidence of complications. Our experiences suggested that the laparoscopic retroperitoneal approach could be effective to overcome those disadvantages of the anterior approach. Herein, we report two cases of successfully treated lumbar pyogenic spondylodiscitis using a robot-assisted laparoscopic retroperitoneal approach. The technique utilizes a robot that allows a laparoscopic retroperitoneal approach while offering excellent high-definition images of three-dimensional vision. After the operation, both patients achieved good formation and fusion of the vertebrae. Preliminary evidence suggests that the robot-assisted laparoscopic retroperitoneal approach may be feasible for the treatment of lumbar spondylodiscitis.

Study on the clinical efficacy of bone-filled mesh vertebroplasty combined with posterior screw and rod internal fixation in the treatment of thoracolumbar metastases: a retrospective cohort study.

BACKGROUND: Thoracolumbar metastases is a difficult disease to deal with in spinal surgery. The aim of this study is to investigate the clinical efficacy of bone-filled mesh vertebroplasty combined with posterior spinal internal fixation in the treatment of thoracolumbar metastases. METHODS: The clinical data of 68 patients with thoracolumbar vertebral metastases from January 2018 to April 2020 were retrospectively analyzed. A total of 37 cases underwent bone filling mesh pocket vertebroplasty combined with posterior spinal internal fixation as the observation group, and 31 cases underwent routine vertebroplasty combined with posterior spinal internal fixation as the control group. The visual analogue scale (VAS) scores, Oswestry disability index (ODI) scores, Karnofsky performance status (KPS) scores, and the heights of the anterior margin and middle of the diseased vertebra were compared between the 2 groups before and 1 week, 3 months, 6 months, and 1 year after surgery. RESULTS: All cases successfully completed the operation, and there was no pulmonary embolism, paraplegia, or perioperative death in follow-up reported. Intraoperative bone cement leakage occurred in 4 cases with a total of 6 vertebrae in the observation group (leakage rate: 14.29%), and in 8 cases with a total of 11 vertebrae in control group (leakage rate: 31.43%). The differences in VAS scores, ODI scores, KPS scores, and the heights of the anterior margin and middle of the diseased vertebra between preoperative and postoperative periods at 1 week, 3 months, 6 months, and 1 year in both groups were statistically significant (P<0.05), while the differences between the 2 groups were not statistically significant (P<0.05). CONCLUSIONS: The application of bone-filled mesh vertebroplasty combined with posterior internal pedicle screws fixation for the treatment of thoracolumbar metastases can not only reduce the injury of the operation, but also achieve the purpose of relieving pain, controlling local tumor growth to a certain extent, restoring neural function, and rebuilding the stability of the spine, which has important clinical value.

Full-endoscopic uniportal retropharyngeal odontoidectomy: A preliminary case report.

Summary of background data: Odontoidectomy aims to decompress the medulla oblongata and is usually performed through the classical transoral approach, which affects oropharynx and accompanied with high rate of complications comprising swallowing and respiratory tract. We have developed a minimal invasive method via a standard cervical anterior approach: full-endoscopic trans-cervical odontoidectomy, which provides an alternative access for the resection of odontoid process and medulla oblongata decompression without traversing potentially contaminated cavities. Methods: From 2018 to 2020, three patients with either odontoid process lesion or basilar invagination underwent full-endoscopic uniportal trans-cervical odontoidectomy with/without combining the posterior instrumentation. With fluoroscopic guidance, a uniportal endoscope sleeve was placed inside of the odontoid process; then odontoid process was gradually resected from the inside to outside under endoscopic monitoring. Postoperative images and clinical data were collected during post-op follow-up. Result: Patients were soon extubated after surgery when patients wake up from general anesthesia. There were no severely perioperative complications, especially dysphagia and airway obstruction, and the symptoms and neurological function was improved immediately after surgery. The final pathology of one patient with odontoid osteolytic lesion was confirmed as plasmacytoma. The postoperative CT scans proved that the range of odontoid process resection was consistent with the preoperative expectation. Conclusion: In summary, our proposed endoscopic trans-cervical odontoidectomy provides a valid choice for non-oral approach, which would reduce postoperative approach related complications and accelerate postoperative recovery.

Retroperitoneoscopic debridement and internal fixation for the treatment of lumbar tuberculosis.

ABSTRACT: To describe the retroperitoneoscopic debridement technique and evaluate the clinical outcome of internal fixation for the treatment of lumbar tuberculosis.Twenty-eight patients were performed conventional laparoendoscopic technique (n = 17) or laparoendoscopic single-site technique (n = 11). Antituberculosis chemotherapy and thoracolumbosacral orthosis were given to all patients. The clinical outcomes were evaluated with preoperative and postoperative Visual Analog Scale, and radiographs with respect to sagittal angle and fusion status.Average time of the 28 procedures was 220.6 ±â€Š50.9 min (180-365 min). The average intraoperative blood loss was 108.6 ±â€Š95.3 mL (50-400 mL). All patients showed significant improvement of their Visual Analog Scale back pain score at follow-up and were classified as having a radiographic fusion in this study. The mean sagittal angle was 11.2 ±â€Š3.6° before operation, significantly improved to 3.7 ±â€Š2.4° after operation. There were no recurrent infections during the follow-up period. Complications included loosening of anterior fixation and temporary deficit of the sympathetic nerve.Retroperitoneal laparoscopic approach with CO2 insufflation technique is a challenging but safe and effective procedure for lumbar spine tuberculosis. Retroperitoneal laparoendoscopic single-site can be used for anterior lumbar spine surgery, offer exposure for L1 through L5.

Percutaneous endoscopic debridement with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis: a preliminary study.

PURPOSE: To access the feasibility and efficacy of percutaneous endoscopic debridement (PED) combined with percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar pyogenic spondylodiscitis. METHODS: Forty-five patients diagnosed as pyogenic spondylodiscitis underwent PPSF followed by PED. A drainage catheter was left in place for negative pressure drainage. Adequate systematic antibiotics were administered empirically or based on bacterial culture results. Clinical outcomes were assessed by physical examination, regular serologic testing, visual analog scale (VAS), Oswestry Disability Index (ODI), and imaging studies. RESULTS: The mean operative time was 110.1 ± 21.2 minutes (range 80-165 minutes), with intra-operative blood loss 47.8 ± 21.0 ml (range 20-120 ml). All patients reported relief of back pain, able to sit up, and partially ambulate the next day. Causative pathogens were identified in 32 of 45 biopsy specimens, staphylococcal bacteria being the most prevalent strain. However, there were 13 patients with post-operative complications. During 6-12 months' follow-up, inflammatory markers showed infection controlled. VAS and ODI values were significantly improved. DISCUSSION: Satisfactory clinical and functional outcomes were achieved in our patients post-operatively. It is recommended that PED plus PPSF can be another alternative for spondylodiscitis. CONCLUSION: PED supplementing PPSF offers a valid option in treating spondylodiscitis, as it is minimally invasive, shortens hospital stay, and avoids prolonged bed rest with an optimistic outcome.

TRIM2 regulates the development and metastasis of tumorous cells of osteosarcoma.

The present study aimed to investigate candidate genes involved in the development and metastasis of osteosarcoma. Candidate genes were screened preliminarily from the Gene Expression Omnibus database and then validated using actual tumor tissues collected from patients with osteosarcoma. The cells were prepared and transfected with specific gene-targeted small interfering RNA followed by an MTS assay for cell viability detection and Transwell assays for cell migration and invasion capacity detection. The cell apoptosis was determined by flow cytometry and the protein level of the genes was detected by western blot analysis. An in vivo nude model was used and injected with cells to detect the functions of the genes. Transcriptome sequencing was performed to verify the regulation network, followed by reverse transcription-quantitative polymerase chain reaction and western blot analyses for validation. Increased tripartite motif-containing protein 2 (TRIM2) was detected in the osteosarcoma tumor tissues compared with normal tissues. The inhibition of TRIM2 induced lower cell viability and cell invasion capacity, and increased the rate of cell apoptosis. Decreased TRIM2 also inhibited the development and metastasis of osteosarcoma in the nude mouse models. The transcriptome sequencing revealed that the regulation of TRIM2 may be correlated with genes, Sirtuin 4, DNA damage inducible transcript 3, cAMP responsive element binding protein 5, G protein-coupled receptor 65 (GPR65) and ADP-ribosyltransferase 5. Western blot analysis indicated that TRIM2 regulated the development and metastasis of osteosarcoma via the phosphoinositide 3-kinase/protein kinase B signaling pathway. Therefore, TRIM2 performs important functions in regulating the development and metastasis of osteosarcoma.

Epidemiological Characteristics of Traumatic Spinal Cord Injury in Guangdong, China.

STUDY DESIGN: A hospital-based retrospective epidemiological study. OBJECTIVE: The aim of this study was to examine the demographic and epidemiological characteristics of patients with traumatic spinal cord injury (TSCI) in Guangdong to help health-related institutions develop measures to determine the best allocation of medical resources. SUMMARY OF BACKGROUND DATA: TSCI is a highly disabling and deadly injury. Currently, there is little information regarding the epidemiological characteristics for TSCI in Guangdong. METHODS: We retrospectively reviewed the medical records of partial second-grade class-A hospitals (mainly capturing general city and county hospitals and some large-scale affiliated hospitals) in Guangdong province according to the International Classification of Disease Version 10 (ICD-10) and diagnostic code of TSCI. RESULTS: The study included the medical records of 1340 patients with TSCI, and the annual number of TSCI admissions increased during the 2003 to 2011 period. The male-to-female ratio was approximately 3.5:1. The major causes of spinal cord injuries were high falls (41.0%) and traffic accidents (37.8%). The most common injury among patients with TSCI was cervical injury (818 cases). In addition, 62.9% of the patients had spinal fractures, 24.0% had other fractures, and 13.7% had brain injuries. Furthermore, 25.1% (337/1340) of the patients experienced clinical complications. The differences in the number of patients with and without complete injury who accepted surgery and hyperbaric oxygen therapy were statistically significant (P < 0.05), and the difference in total medical cost was significant (P < 0.05). CONCLUSION: There are specific epidemiological characteristics of TSCI patients in Guangdong, and preventive measures are suggested to focus on high-risk populations, such as adult men. LEVEL OF EVIDENCE: 3.

Comparison of smith-petersen osteotomy, pedicular subtraction osteotomy, and poly-segmental wedge osteotomy in treating rigid thoracolumbar kyphotic deformity in ankylosing spondylitis a systematic review and meta-analysis.

BACKGROUND: This study aimed to compare Smith-Petersen osteotomy (SPO), poly-segmental wedge osteotomy (PWO) and pedicular subtraction osteotomy (PSO) in patients with rigid thoracolumbar kyphosis primarily caused by ankylosing spondylitis. The efficiency, efficacy and safety of these three osteotomies have not been compared systematically, and no illness-oriented surgical type selection strategy for the treatment of ankylosing spondylitis related to non-angular kyphosis has been reported. METHODS: The inclusion and exclusion criteria were defined, and 19 electronic databases were searched for eligible studies without language limitations. For the included studies, data extraction, bias analysis, heterogeneity analysis and quantitative analysis were performed to analyze the correction of kyphosiskyphosis and the incidence of complications. RESULTS: Nine comparative studies that met the standards were included with a total of 539 patients that underwent SPO (n = 120), PWO (n = 119), or PSO (n = 300). The correction of kyphosis by PSO was 8.74° [95% CI: 0.7-16.78] greater than SPO. The correction of kyphosis by PWO was 13.88° [95 % CI: 9.25-18.51] greater than SPO. For local biomechanical complications, the pooled risk ratio of PWO to PSO was 1.97 [95 % CI: 1.03-3.77]. For blood loss, PSO was 806.42 ml [95% CI: 591.72-1021.12] greater than SPO and 566.76 ml [95 % CI: 129.80-1003.72] greater than PWO. CONCLUSIONS: To treat rigid thoracolumbar kyphosis, PSO showed higher efficiency and efficacy than SPO, and PWO had a higher efficacy than SPO. The risk of local biomechanical complications was greater in PWO than PSO. Bleeding was more severe in PSO than in SPO or PWO. The incidence of neural complications and systemic complications was similar.

[Total en-bloc spondylectomy for recurrence spinal tumor].

OBJECTIVE: To evaluate the clinical outcomes of total en-bloc spondylectomy (TES) in recurrence spinal tumor. METHODS: The study was a retrospective study of recurrence spinal tumor from January 2010 to October 2013. A total of 6 patients with recurrent spinal tumor underwent TES procedures, with 5 cases located in thoracic spine and 1 case located in L1. There were 3 male and 3 female patients, with a mean age of 33.2 years. Pathological diagnosis included giant cell tumor of bone in 3 cases, breast cancer, lung cancer and nasopharyngeal carcinoma with 1 case in each. The operation time, bleeding loss, resected segments, cutting edge, spinal cord function and complications was evaluated. RESULTS: Single segment resected in 1 case, 2 segments resected in 2 cases and 3 segments resected in 3 cases. The average operation time was 8.9 hours (7.5 to 12.0 hours). The average blood loss was 3 116 ml (2 500 to 4 500 ml). The average follow-up period was 23.2 months (12 to 47 months) without recurrence. There was no spinal cord injury during operation. The neurologic function was significantly improved in 2 cases (American Spinal Injury Association (ASIA) grade C to grade D), unchanged in 1 cases (ASIA grade B) and no deteriorated case in 3 cases (ASIA grade E). There was no perioperative deaths case. Complications included 2 cases pleural rupture, 1 case dural tear and 1 case massive haemothorax. No peri-operation death case. CONCLUSION: Some of the recurrent spinal tumors are still suitable for en-bloc resection and TES procedure with the extent of its applicability under strict control.

Effects and safety of allogenic mesenchymal stem cell intravenous infusion in active ankylosing spondylitis patients who failed NSAIDs: a 20-week clinical trial.

Our objective was to evaluate the feasibility, safety, and efficacy of intravenous (IV) infusion of allogenic mesenchymal stem cells (MSCs) in ankylosing spondylitis (AS) patients who are refractory to or cannot tolerate the side effects of nonsteroidal anti-inflammatory drugs (NSAIDs). AS patients enrolled in this study received four IV infusions of MSCs on days 0, 7, 14, and 21. The percentage of ASAS20 responders (the primary endpoint) at the fourth week and the mean ASAS20 response duration (the secondary endpoint) were used to assess treatment response to MSC infusion and duration of the therapeutic effects. Ankylosing Spondylitis Disease Activity Score Containing C-reactive Protein (ASDAS-CRP) and other preestablished evaluation indices were also adopted to evaluate the clinical effects. Magnetic resonance imaging (MRI) was performed to detect changes of bone marrow edema in the spine. The safety of this treatment was also evaluated. Thirty-one patients were included, and the percentage of ASAS20 responders reached 77.4% at the fourth week, and the mean ASAS20 response duration was 7.1 weeks. The mean ASDAS-CRP score decreased from 3.6 ± 0.6 to 2.4 ± 0.5 at the fourth week and then increased to 3.2 ± 0.8 at the 20th week. The average total inflammation extent (TIE) detected by MRI decreased from 533,482.5 at baseline to 480,692.3 at the fourth week (p > 0.05) and 400,547.2 at the 20th week (p < 0.05). No adverse effects were noted. IV infusion of MSCs is a feasible, safe, and promising treatment for patients with AS.

The vascular supply to the spinal cord and its relationship to anterior spine surgical approaches.

BACKGROUND CONTEXT: The understanding of vascular supply to the spinal cord is important given that the evolution of surgical approaches to the spine may bring along the potential for more frequent complications, especially a rare but devastating complication: that of spinal cord ischemia or infarction. To maximally avoid this complication, the relationship between the spinal cord vascularity and the anterior spine surgical approach needs further study. PURPOSE: To provide a theoretical basis that will allow the spinal surgeon to take appropriate steps to avoid spinal cord ischemia during anterior spinal surgery through anatomic means. STUDY DESIGN: Spinal cord vascular casting assessment with cadaveric specimen. METHODS: Twenty adult cadaveric specimens (11 men and 9 women) were obtained for the latex perfusion and vessel dissection. In addition, nine patients (seven men and two women) underwent superselective angiography of the spinal cord. The segmental arterial anastomosis and radiculomedullary vessels in the thoracolumbar region were shown and reviewed. RESULTS: There were approximately 21 pairs of segmental arteries in the thoracolumbar region. Adjacent segmental arteries were networked with each other. The latex infusion specimens demonstrated 72 anterior radiculomedullary arteries and 177 posterior radiculomedullary arteries in all 20 samples. The anterior and posterior spinal arteries were also networked with each other at several levels. Superselective spinal angiography was consistent with the latex infusion specimens showing. CONCLUSIONS: The variety of anatomy of spinal cord arterial networks is shown, and the relation between the blood supply of certain spinal levels and the potential ischemic complications during the anterior surgical approach is discussed. It is hopefully of benefit to surgeons, after fully understanding the anatomy of these spinal vascular supply structures, that there may be even greater avoidance of vascular compromise in these challenging operations.

Modified total en bloc spondylectomy for thoracolumbar spinal tumors via a single posterior approach.

PURPOSE: The objectives of this study were to describe our surgical management with a modified total en bloc spondylectomy (TES) and to evaluate the clinical effects in patients with thoracolumbar tumors. METHODS: Sixteen consecutive patients with thoracolumbar neoplasms underwent a modified TES via single posterior approach followed by dorsoventral reconstruction from December 2008 to July 2011. Details of the modified technique were described and the patients' clinical information was retrospectively reviewed and analyzed. RESULTS: Significant improvements in neurological function were achieved in most of the patients. Local pain or radicular leg pain was relieved postoperatively. The mean operation time was 7.2 h, with an average blood loss of 2,300 ml. No major complications, instrumentation failure or local recurrence was found at the final follow-up. Five patients died of the disease during mean 14-month (3.0-23) follow-up. CONCLUSIONS: The modified TES with a single posterior approach is feasible, safe and effective for thoracolumbar spine tumors.

Reduced immunomodulation potential of bone marrow-derived mesenchymal stem cells induced CCR4+CCR6+ Th/Treg cell subset imbalance in ankylosing spondylitis.

INTRODUCTION: Ankylosing spondylitis (AS) is a chronic autoimmune disease, and the precise pathogenesis is largely unknown at present. Bone marrow-derived mesenchymal stem cells (BMSCs) with immunosuppressive and anti-inflammatory potential and Th17/Treg cells with a reciprocal relationship regulated by BMSCs have been reported to be involved in some autoimmune disorders. Here we studied the biological and immunological characteristics of BMSCs, the frequency and phenotype of CCR4+CCR6+ Th/Treg cells and their interaction in vitro in AS. METHODS: The biological and immunomodulation characteristics of BMSCs were examined by induced multiple-differentiation and two-way mixed peripheral blood mononuclear cell (PBMC) reactions or after stimulation with phytohemagglutinin, respectively. The interactions of BMSCs and PBMCs were detected with a direct-contact co-culturing system. CCR4+CCR6+ Th/Treg cells and surface markers of BMSCs were assayed using flow cytometry. RESULTS: The AS-BMSCs at active stage showed normal proliferation, cell viability, surface markers and multiple differentiation characteristics, but significantly reduced immunomodulation potential (decreased 68 ± 14%); the frequencies of Treg and Fox-P3+ cells in AS-PBMCs decreased, while CCR4+CCR6+ Th cells increased, compared with healthy donors. Moreover, the AS-BMSCs induced imbalance in the ratio of CCR4+CCR6+ Th/Treg cells by reducing Treg/PBMCs and increasing CCR4+CCR6+ Th/PBMCs, and also reduced Fox-P3+ cells when co-cultured with PBMCs. Correlation analysis showed that the immunomodulation potential of BMSCs has significant negative correlations with the ratio of CCR4+CCR6+ Th to Treg cells in peripheral blood. CONCLUSIONS: The immunomodulation potential of BMSCs is reduced and the ratio of CCR4+CCR6+ Th/Treg cells is imbalanced in AS. The BMSCs with reduced immunomodulation potential may play a novel role in AS pathogenesis by inducing CCR4+CCR6+ Th/Treg cell imbalance.